Physical Exam Pearls – 2 (HENT)

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More in our series of random tips on performing physical exam. Last time we discussed the Eye. Moving on down (and around)…

HEAD

1. We chart “atraumatic,” only because there’s nothing else to say about the adult head (we never chart “Chest, atraumatic,” etc.!!!)

2. In the case of head trauma with normal mental status or slight disorientation, examine for subtle signs of basilar skull fracture:

Choke up on the handle, so your hand is right up near the light source

That way you can brace your 4th & 5th fingers against patient’s jaw or cheek. This is essential in pediatrics, lest the child wiggle, jamming their ear into the otoscope speculum

2. Tug on the pinna to straighten the canal; be as aggressive as you need. I’ve seen countless students find a “red TM” when all they were seeing was the canal wall.

3. Seek bony landmarks every time you examine the TM. Can’t evaluate it otherwise. Presence / absence of landmarks is much more important than the color when it comes to Otitis Media.

Increased vascularity of TM along the bony landmark looks “red,” but is NOT Otitis Media.

Cone of light not as important in adults, since old infections may have distorted it.

4. A single reddish spot on TM is probably pasted-on wax, but stare at it carefully. If it pulsates, it’s a rare vascular tumor [have never seen one].

5. Seek out a cholesteatoma — white lesion / nodule usually at the superior aspect of TM. Needs ENT evaluation, since it can erode into bone.

6. Ear Pain & too much wax / gook to visualize the TM — tug on pinna & push on tragus. If these maneuvers are tender, it’s Otitis Externa. If not, then no Externa (so maybe Media, if the pain is significant).

7. Weber Test (tuning fork) — Explain to patient, “I’m going to hit the fork to make a tone, ‘Buzzzz,’ put it on your head, & you tell me, is it louder in this ear [point] or that one [point].”

I’ve had several patients worry about “tongue cancer,” when they’d happen to notice normal papillae way in the back of their tongues. Though I usually don’t reveal personal information to patients, I do stick out my own tongue as reassurance.

2. Every time I examine the mouth & throat, I look for stigmata of occult undiagnosed HIV.